I had been in post for some time when there was a reported incident of Oliver Maxwell allegedly throwing a scalpel in the direction of an anaesthetic technician during an operating theatre procedure. If this was proven to be the case, there would be extremely serious consequences for Mr. Maxwell. The technician was adamant that the scalpel had been thrown in a fit of temper and had just missed his face. A disciplinary hearing was convened which was chaired by my boss, the hospital general manager. There was a succession of witnesses called which included nursing staff, the anaesthetic technicians, and a junior doctor training to be a surgeon, an anaesthetic registrar and the consultant anaesthetist. The hearing was held over a two day period and my boss said that it was very intense. Essentially there was a polarisation of camps – the anaesthetic technician and registrar reported that the scalpel had been deliberately thrown with some force. It was accepted by these staff there was no intent to throw it at the technician. The nurses present were ambivalent claiming to have been engaged on other activities when the knife was thrown. Oliver Maxwell’s stance was that the scalpel point had pierced the surgical glove and cut his finger and as a result the scalpel had flown out of his hand in an involuntary reaction to his finger being pricked. This view was supported by the consultant anaesthetist – it would have been surprising if he didn’t as he ‘gassed’ for Maxwell when he was operating on private patients. The end result was a formal, written warning. The surgeon appealed but the original decision was upheld by the chairman of the health authority. What proved to be interesting was the movement of staff over the following few months. The anaesthetic technician found a post in another hospital – allegedly his life had been made a misery since the incident was reported. The anaesthetic registrar was almost definitely hounded out with a smear campaign of supposed alcohol abuse. The junior surgeon completed his training at Oldshire and then moved on to his next hospital. This was just a natural progression but although broadly supportive of Maxwell’s version of events at the disciplinary hearing, the general manager thought the junior doctor was ‘jittery’ and had been ‘got at’. This just left the nurses and the consultant anaesthetist from the team interviewed at the disciplinary hearing. Not forgetting, of course, Oliver, the Lord Protector of the operating theatres at Oldshire.

  THE MATRIX

  – Healthcare Politics, ‘The Great Game’

  Politics and healthcare are inextricably linked. It is an irresistible combination that can never fully be severed and that is not just in a parochial British context. In dozens of settings throughout the world, there is a distinct political dimension whenever healthcare is involved. Even in the United States, which has both the world’s largest economy and the world’s biggest health economy, much of it outside public hands, the spectre of healthcare always has the potential to frighten politicians. Hillary Clinton will bear witness to this from the early 1990s. In the twenty years since, Barack Obama has managed to ram through legislation but it has taken a huge amount of energy and legislative time. Healthcare without politics is almost unimaginable – a bit like Egypt without the pyramids. The politics is at two levels, the macro political dealing with external forces and those politics of the internal type. Anecdotally, I can remember being told that the most devious and effective application of organisational or ‘office politics’ is found in academic settings. The second most is in healthcare and in particular, hospitals. So for hospitals attached to universities, it really must be a rum old game, a rigorous and unforgiving one at that. Incidentally, the brother of a good friend of mine is dean at one of the largest medical schools in Europe. I have never actually met him but it would be fascinating to have a discussion with him.

  For the external politics, whether public or private sector, the government or their agents, the Department of Health, are the drivers. This in healthcare terms, has become the latter day ‘Great Game’ – how to operate and co-exist with the centre or on occasions even outmanoeuvre the Whitehall mandarins if desirable and feasible. The original ‘Great Game’ was a phrase attributed to Arthur Conolly who was an intelligence officer operating in India during the middle of the nineteenth century and it was later popularised by Rudyard Kipling. The ‘game’ related to the British-Russo conflicts in exerting influence over central Asia with the defence of India the essential British strategy. At times, dealing with central directives and their implementation can reflect the ‘vast chessboard’ of the initial ‘Great Game’ – the ability to read the runes accurately is a prerequisite to long-term survival.

  In the United Kingdom no government can afford to ignore or dismember the NHS. The umbilical cord between the public and their NHS is as tangible now as ever. It should also be recognised that users of the health service, as with twenty-first century consumers in general, are more critical and vocal about both expectations and delivery of care. This does not mean that there would be any great support to dismantle the health service and replace it with an insurance based system but users tend to be more sophisticated and knowledgeable than a generation previously. This is recognised by all of the major political parties and therefore changes to health provision are applied through ‘reforms’ and ‘reorganisations’ rather than anything that can be publicly perceived as disassembling the structure. The façade may need some attention from time to time, a few coats of paint and the like but the supporting walls should not be moved under any circumstances. The government of the day, like it or not, has to both recognise and accept that the provision of public healthcare is an essential part of the British social fabric. It is interesting how the centralist message is driven down. During the 1980s when the Conservative Party formed the government, the chairs of many health authorities who were appointed in effect by the government, were party loyalists and often members. This made it easier for more contentious decisions such as contracting out of services or even hospital closures to be carried out. As always there were two sides to the health Great Game and with the Labour Party victory in 1997, the placement of Labour supporters and sympathisers became more prominent.

  Private (or ‘independent’) healthcare did not escape the attention of central government, not even a supposedly sympathetic Conservative one. The price structure within the independent health sector is a vital part of their business planning and a key feature of how they will compete. Even if the independent hospital is a ‘not for profit’ institution, a surplus has to be generated for investment whether additional beds or equipment. In the mid 1980s, with inflation declining but still evident, the charges for pay beds in NHS hospitals remained static for two years. The charges were set by the centre and to leave them unchanging was a distinctly political act that affected private sector revenues which at the time tended to compete against the NHS pay bed rates.

  For clinicians, the thrust of the government’s policies can often have a more than marginal impact on how clinical care is made available. Over fifteen years ago, I had a discussion with a cardiac surgeon and one of the points he made related to the tangible results that the general population could observe about the direction that healthcare and the NHS was taking. I would not pretend to know, or even guess, how he chose to exercise his vote but one of his comments was that ‘the government have spent billions and billions on the NHS with very little to show for it’. His point being that public perception of the contemporary government was a floundering NHS and spending perhaps being restrained when in real terms money had been shovelled in at historically high rates. For the surgeon, one of his primary concerns was that not enough of his patients were being offered the necessary treatment in a timely manner. The distaste that some doctors had for what were, in effect, government led centralist directives was very apparent, particularly in the immediate years following the implementation of trusts and the internal market. One consultant told me in a frustrated manner –“It’s the catch phrase mentality from the politicians such as waiting list initiative that is so unseemly and exasperating. We seem to have office blocks of people who have to think up more acronyms and jargon, for example FCE (finished consultant episode), HRG (health resource group) and on it goes. Why can’t they just leave us alone?” was his plaintive question. Around this era I was visiting a neighbouring hospital where I had worked previously and met up with a senior doctor with whom I had worked on a project a few years back. I knew him reasonably well although I had not seen him for a couple of years. We were catching up about some things including how the thrust of the internal market was affecting the hospital. Being a time of rapid change, I asked him who he thought controlled change in his hospital. The instant reply was, “Virginia Bottomley!” who was Secretary of State for Health at the time – and Mistress of the Great Game.

  I’M ALL RIGHT JACK

  – The Unions

  Most of my time in NHS healthcare involved at least some dealings with trade unions. In some instances, the relationship was very formal and hospital administrators were seen as the enemy, with other individuals it was a more pragmatic dialogue that could switch from the informal to the official when the context demanded. There was one union representative who I had some dealings with when some staff responsibilities were being reshaped and it involved changes in the work place for some of the staff. Derek and I used to have some banter, mainly about football, but did get agreement on how the changes should be implemented. The final meeting was shortly before Tony Blair’s landslide election victory in 1997 and Derek mentioned in passing that he had been asked to address a socialist meeting a couple of evenings previously. I quipped, “Well it obviously wasn’t a Labour Party meeting!” which earned me a withering look. There was some enjoyment in negotiating with people I regarded as genuinely putting the best interest of their members first. On some sad occasions I was convinced that bloody-mindedness and obsession with the ‘class war’ had been the motives for some dire decisions that adversely affected trade union members usually to their financial detriment. A case in point was the grading negotiations with medical secretaries at one hospital I worked at. The local union representative got heavily involved and strike action took place. Most of the medical secretaries in the hospital’s two sites withdrew their labour for one day. It happened to be a wet autumn day and the local paper had a photo of glum-faced secretaries huddling beneath umbrellas by the hospital entrance. In fact, there was only one secretary, who happened not to be a union member, which refused to strike. Ironically, her salary was cut by a day’s pay that month before it was readjusted when the mistake was rectified. In the instance of the grading process, I feel sure the medical secretaries would have benefited with new grades without having to resort to striking and losing a day’s pay.

  The trade union officials tended to be split fairly evenly between men and women. At one hospital I worked at, there was a very active branch secretary called Elizabeth Urqhart, who represented the Really Special Healthcare Union (RSHU). Elizabeth and I had business dealings within a week of my starting which culminated in me sacking one of her members. Over the next month it seemed the former staff member would appeal against the decision by applying for a hearing with an industrial tribunal. Elizabeth would pointedly say whenever we met that the tribunal was not too far away. Eventually as time went by Elizabeth admitted her ex-member had lost interest and would not be lodging an appeal. Ms.Urqhart had had an interesting career to date. Judging by her general appearance I would imagine she was in her mid-thirties and until the year I joined the hospital, she had been a local councillor for some years. In the lead up to the 1992 general election, Elizabeth brought the regional union representative, Frank Rulfi, to visit the hospital. He was allowed to tour around the site but the chief executive did request that I accompany the small party, so I joined Elizabeth and Frank Rulfi as they went round the hospital. Rulfi was good company and I could see why he had reached his position – he was very sharp on the uptake, dressed very smartly (a socialist in the Derek Hatton vein) and was very affable. He even had curls in his hair, I’m not sure if they were genuine but they gave him the appearance of a trendy 70’s footballer. We had toured round the hospital and stopped briefly outside one clinic where an elderly gentleman was sitting.

  “Hello, I’m Frank Rulfi from the RSHU. Can Labour count on your vote in the election?”

  The patient glowered up at Rulfi – “And how much are you going to get inflation up to this time?” he snapped. Rulfi grinned amiably but I could see this had rattled Elizabeth and she was not amused by the incident. She ushered us on quickly – in an hour spent touring various parts of the hospital, this was the first overt dissent that had been heard. We went to the cafeteria and had coffee. Rulfi was unperturbed by the patient’s reaction and recounted a meeting with the chief executive of a large hospital in a neighbouring city. The CEO was notorious for his ‘macho management’ approach, which had won him few friends and admirers amongst management ranks, let alone the clinical profession.

  Rulfi entertained us – “I had an interesting meeting with Nigel Rainham a few days back. The guy looked under pressure, really drawn and tired. He looked like the anti-Christ.” Then after a brief reflection he added, “In fact, I think Nigel Rainham might actually be the anti-Christ,” which made both myself and Elizabeth chuckle. I had the distinct impression that Ms.Urqhart was an ambitious union activist and was keen to impress any visiting luminaries of the union hierarchy.

  The other main union rival active on that hospital site was a veteran union branch secretary who was probably in his sixties at the time, he was Bob Seagrave of the Extremely Good Health Association (EGHA). Bob was a full-time official and therefore not resident on the site but his influence did extend. He actually wore a cloth cap as if acting out the stereotype of a solid, union man and came across as a bluff, no nonsense old school trade union activist. It did cross my mind what Bob may have thought of Frank Rulfi’s style and representation of union members’ needs – there was certainly a generation gap. An aspect I found amusing was the race between EGHA and RSHU for members when a newly joined member of staff admitted they had no union membership or affiliation – the race between Bob and Elizabeth was on, with Ms. Urquart usually winning by virtue of her being a part-time union official and full-time member of staff. The first time I met Bob, he sat in my office and presented a potted history of British industrial relations since the mid-nineteenth century, all done in a flat, humourless tone that was didactic for my benefit. My last dealing with him was by phone when he was trying to get one of his members reinstalled following a resignation. The member had been drinking at lunchtime whilst driving a hospital van and I had suspended him pending a disciplinary hearing. The driver, wisely in my view, resigned making it an easier situation all round. Bob tried to intervene by phone, citing cases of health authorities that had to pay compensation for unfair dismissal. I knew Bob was trying it on – “Your member resigned,” I reminded Bob. “If he wants to sue for constructive dismissal, he can – but I don’t think that would be the best use of your union’s resources.” That was the last I heard from Bob Seagrave.

  A feature of the NHS since the 1974 reorganisation was a body called the Joint Staff Consultative Committee (JSCC) where union and staff representative associations formally met with management, usually on a monthly basis to identify issues and resolve them where it was practical. I sat on the JSCC at two different hospitals and although in both instances there was a lot of people attending, probably around twenty in both instances, I felt that they offered good value for at least two reasons. Firstly I saw that quite a lot of things got fixed and in NHS terms they were fixed quickly. At one hospital it was a perennial smoking issue and whether smoking should be allowed in a dining room (this was over twenty years ago) and the solution was a smoking room within a room. A second example was the addition of the so called ‘stat’ or statutory days to the staff members’ annual leave allocation. The stat days were two days added to bank holidays, one at Spring Bank Holiday, the other at August Bank Holiday. The proposal was for these days to be added to the holiday of the individual. A major gain was that two additional days in the year became available for the hospital to function on a regular basis for patients – with outpatient clinics, operating theatre procedures and standard diagnostic facilities available. Secondly, a common and persistent criticism about hospitals (and other large and complex workplaces) is that communication is not very effective. The JSCC was an opportunity for relatively junior staff to see at first hand and have dialogue with senior members of the team. In both committees that I participated in the chief executive was a regular attendee and messages from management were delivered first hand without embellishment or through a third party. And from the staff direction, the factors that were of greatest concern were brought to the attention of the most senior managers in an undiluted manner.

 

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